Healthcare Provider Details

I. General information

NPI: 1619397601
Provider Name (Legal Business Name): JACLYN BROTHERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 W BRISTOL RD
FLINT MI
48507-3170
US

IV. Provider business mailing address

4466 W BRISTOL RD
FLINT MI
48507-3170
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-1200
  • Fax: 810-733-0688
Mailing address:
  • Phone: 810-733-1200
  • Fax: 810-733-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: